Medication Record

Patient Name: Age:

Sex:
Patient No.: Ward/Rm No.:

Nurse’s Name Initial Nurse’s Name  Initial

Date
Medications
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 Intake and Output Monitoring Record

Patient Name: Age:. Sex:

Patient No.: Ward/Rm No.:

Date/ INTAKE OUTPUT

Shift

Or IV Others (TPN, Blood Subt Uri Sto Others (Emesis, Subt

al F Products, Meds) otal ne  ol Drainage) otal

6am -
2pm

2pm -
10pm

10pm -
6am

Or IV Others (TPN, Blood Subt Uri Sto Others (Emesis, Subt

al F Products, Meds) otal ne  ol Drainage) otal

6am -
2pm

2pm -
10pm

10pm -
6am

Or IV Others (TPN, Blood Subt Uri Sto Others (Emesis, Subt

al F Products, Meds) otal ne  ol Drainage) otal

6am -
2pm

2pm -
10pm

10pm -
6am

Or IV Others (TPN, Blood Subt Uri Sto Others (Emesis, Subt

al F Products, Meds) otal ne  ol Drainage) otal

6am -
2pm

2pm -
10pm

10pm -
6am

IV Fluid Record
Patient Name: Age: Sex:
Patient No.: Ward/Rm No.:

Starte
d

Date Time Type of Started Medication added Medication Remarks

Solution/Amount/Rate by: or amount infused Added by: